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1 ~ CERTHOLDER COPY NA STATE CO", PEN 5 A - 0 N NStJ~A.NCE P.O. BOX 420807, SAN F.RANCISCO,CA 94142-0807 FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 04-22-2010 GROUP: 000571 POLICY NUMBER: 0004041-2009 CERTIFICATE ID: 113 CERTIFICATE EXPIRES: 10-01-2010 10-01-2009/10-01-2010 CITY OF REDWOOD CITY 1017 MIDDLEFIELD RD REDWOOD CITY CA 94063-1993 NA ~OB:SANITARY SEWER PUMO STATION 112 This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California Insurance Commissioner to the employer named below for the policy period indicated. This policy is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer. We will also give you 30 days advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend. extend or alter the coverage afforded by the policy listed herein. Notwithstanding any requirement. term or condition of any contract or other document with respect to which this certificate of insurance may be issued or to which it may pertain. the insurance afforded by the pOlicy described herein is subject to all the terms. exclusions. and conditions, of such policy. ':b+ Vl/iM.,/ thorized Representative Interim President and CEO EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. ENDORSEMENT #0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2009-10-01 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED: CITY OF REDWOOD CITY ENDORSEMENT #1600 - MEL CASEY PRES,TREAS - EXCLUDED. ENDORSEMENT #1600 - MARGUERITE CASEY SEC - EXCLUDED. _____ ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 10-01-2006 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. EMPLOYER CASEY CONSTRUCTION, INC 620 HANDLEY TRL EMERALD HILLS CA 94062 NA [CMS,CS] (REV. 1-20101 PRINTED 04-22-2010